Arthroscopic Tibiotalar Arthrodesis versus Open Arthrodesis with Anterior Locking Plate: A Retrospective Case Series

Category: Ankle; Ankle Arthritis; Arthroscopy Introduction/Purpose: Tibiotalar arthrodesis is a common procedure for the treatment of ankle arthritis. Arthroscopic arthrodesis with screw fixation has become increasingly popular with reported shorter hospital stays, shorter time to fusion, and equivalent patient reported outcomes to open arthrodesis with screw fixation. However, there is limited research comparing arthroscopic arthrodesis to open arthrodesis with a modern anterior locking plate. The aim of this study was to determine if the use of a modern anterior locking plate in primary ankle arthrodesis would have a similar time to fusion versus arthroscopic arthrodesis with screw fixation. Methods: We performed a retrospective case review of primary ankle arthrodesis cases from 2009 to 2018 that utilized either an open approach with an anterior locking plate or an arthroscopic approach with screw fixation. All open cases were performed by a single surgeon using an anterior locking plate; all arthroscopic cases were performed by another surgeon using cannulated screw fixation. Post-operative protocol was similar for both patient groups, with at least 6 weeks of casting and protected weight- bearing followed by a transition to removable cast-boot and progressive weight-bearing. Exclusion criteria included combined tibiotalar/subtalar arthrodesis, hindfoot arthrodesis, cases where infection was suspected pre-operatively, and revision arthrodesis for any reason (IE, infection, failed total ankle arthroplasty, prior nonunion). Time to fusion was based on evaluation of post- operative radiographs performed at six and ten weeks. Results: 28 open and 25 arthroscopic arthrodesis cases met inclusion criteria. The fusion rate at six weeks was 82.1% (open) versus 72% (arthroscopic). At ten weeks the fusion rate was 100% (open) versus 91% (arthroscopic). 4/28 open arthrodesis cases experienced continued pain versus 8/25 arthroscopic. For the open procedure, one patient required reoperation for skin grafting away from the incision due to a poor-fitting workboot. Two patients had removal of painful hardware; one of these patients required a second reoperation for symptomatic neuroma resection. For arthroscopic cases, two patients had removal of hardware and one patient had an elective below-knee amputation for intractable pain. Average patient age was 53.3 years (open) versus 48.4 (arthroscopic). Average length of hospital admission was 2.3 days (open) versus 0.9 (arthroscopic). Conclusion: Open tibiotalar arthrodesis with a modern anterior locking plate resulted in faster time to radiographic fusion and a lower incidence of continued pain compared to arthroscopic arthrodesis in this study. The faster time to fusion may be due to the superior biomechanical stability of a locking construct. Arthroscopic arthrodesis resulted in shorter hospital admissions, and neither group had any incision-related complications. In this case series, open and arthroscopic fusion had comparable outcomes.

Effectiveness of distal tibial osteotomy with distraction arthroplasty in varus ankle osteoarthritis

Background: Advanced to end-stage ankle osteoarthritis in highly active older individuals has traditionally been treated using tibiotalar arthrodesis. With tibiotalar arthrodesis, high levels of pain-free function are possible; however, there is a loss of ankle joint movement and a risk of future arthrosis in the adjacent joints. Distraction arthroplasty is a simple method that allows joint cartilage repair; however, the results are currently mixed, with some reports showing improved pain scores and others showing no improvement. Distal tibial osteotomy (DTO) without fibular osteotomy, a type of joint preservation surgery, has garnered attention in recent years. However, to our knowledge, there are no reports on DTO with joint distraction using a circular external fixator. Therefore, the purpose of this study was to examine the effect of DTO with joint distraction using a circular external fixator on ankle osteoarthritis. Methods: A total of 21 patients with medial ankle arthritis were examined. Arthroscopic synovectomy and a microfracture procedure were performed. Subsequently, angled osteotomy and correction of the distal tibia were performed. After ankle conditions improved, stabilization of the ankle joint was performed. An external fixator was used in all patients. In addition, joint distraction of about 5.8 mm was performed. All patients were allowed full weight-bearing walking immediately after surgery. Results: The anteroposterior mortise angle during weight-bearing, lateral mortise angle during weight-bearing, and talar tilt angle and anterior translation of the talus on ankle stress radiography significantly improved (P < 0.05). In addition, signal changes on magnetic resonance imaging improved in all patients. Visual analogue scale and American Orthopedic Foot & Ankle Society scores also improved significantly (P < 0.05). No severe complications were observed. Conclusion: DTO with joint distraction may be useful for older patients with a high physical activity level as a joint-preserving surgery for medial ankle osteoarthritis. Level of evidence: Level IV, retrospective case series Key words : distal tibial osteotomy, medial ankle arthritis, joint distraction, circular external fixator

Tibiotalar Arthrodesis Using a Hybrid Technique with a New Low-profile Anatomic Plate and Two Compression Screws: First One-year Results of Twenty Patients

Background: The aim of this prospective study was to evaluate and analyse the first clinical results of a recently developed low-profile anatomic plate in combination with two headless compression screws for tibiotalar arthrodesis. Methods: The case series involved 20 consecutive patients who underwent ankle arthrodesis using a hybrid technique. Radiographs were obtained at 6 and 12 weeks and 1 year postoperatively. The outcome was evaluated by using AOFAS and SF 12-questionnaire. Any complications related to the arthrodesis were recorded. Results: The follow-up rate was 100%. Patients mean age at the time of surgery was 60.1 years (range, 40-79). Arthrodesis with full weight-bearing occurred in every patient within 12 weeks postoperatively. There were no patients with delayed union, non-union, infection or implant failure. AOFAS Score and SF-12 scores increased considerably compared to preoperatively. Conclusion: The hybrid technique for ankle arthrodesis is a tibiotalar compression with screws in combination with rigid anterior plate fixation. Our clinical results demonstrated no implant failure, no infection and fusion in any of the 20 patients. Further studies are necessary to support our first results.

Effectiveness of distal tibial osteotomy with distraction arthroplasty in varus ankle osteoarthritis

Background: Advanced to end-stage ankle osteoarthritis in highly active older individuals has traditionally been treated using tibiotalar arthrodesis. With tibiotalar arthrodesis, high levels of pain-free function are possible; however, there is a loss of ankle joint movement and a risk of future arthrosis in the adjacent joints. Distraction arthroplasty is a simple method that allows joint cartilage repair; however, the results are currently mixed, with some reports showing improved pain scores and others showing no improvement. Distal tibial osteotomy (DTO) without fibular osteotomy, a type of joint preservation surgery, has garnered attention in recent years. However, to our knowledge, there are no reports on DTO with joint distraction using a circular external fixator. Therefore, the purpose of this study was to examine the effect of DTO with joint distraction using a circular external fixator on ankle osteoarthritis. Methods: A total of 21 patients with medial ankle arthritis were examined. Arthroscopic synovectomy and a microfracture procedure were performed. Subsequently, angled osteotomy and correction of the distal tibia were performed. After ankle conditions improved, stabilization of the ankle joint was performed. An external fixator was used in all patients. In addition, joint distraction of about 5.8 mm was performed. All patients were allowed full weight-bearing walking immediately after surgery. Results: The anteroposterior mortise angle during weight-bearing, lateral mortise angle during weight-bearing, and talar tilt angle and anterior translation of the talus on ankle stress radiography significantly improved (P < 0.05). In addition, signal changes on magnetic resonance imaging improved in all patients. Visual analogue scale and American Orthopedic Foot & Ankle Society scores also improved significantly (P < 0.05). No severe complications were observed. Conclusion: DTO with joint distraction may be useful for older patients with a high physical activity level as a joint-preserving surgery for medial ankle osteoarthritis. Level of evidence: Level IV, retrospective case series Key words : distal tibial osteotomy, medial ankle arthritis, joint distraction, circular external fixator

Effectiveness of distal tibial osteotomy with distraction arthroplasty in varus ankle osteoarthritis

Background Advanced to end-stage ankle osteoarthritis in highly active older individuals has traditionally been treated using tibiotalar arthrodesis. Tibiotalar arthrodesis is possible to have high levels of pain-free function, however there is loss of ankle joint movement and a risk of arthrosis of adjacent joints in the future. Distraction arthroplasty is a simple method with a possibility of the joint cartilage repair but current results are mixed with reports of patients with better pain scores and some without any improvement. Distal tibial osteotomy (DTO) without fibular osteotomy, a type of joint preservation surgery, has garnered attention in recent years, However, as far as we know, there are no reports on DTO with joint distraction using a circular external fixator. The purpose of this study was to examine the effect of DTO with joint distraction using a circular external fixator on ankle osteoarthritis.Materials and Methods A total of 21 patients with medial ankle arthritis were examined. Arthroscopic synovectomy and a microfracture procedure were performed. Then angled osteotomy and correction of the distal tibia were performed. After ankle conditions improved, the stabilization of the ankle joint was performed. An external fixator was used in all patients. In addition, joint distraction of about 5.8 mm was performed. All patients were allowed full weight-bearing walking immediately after surgery.Results Antero-posterior mortise angle during weight-bearing, lateral mortise angle during weight-bearing, and talar tilt angle and anterior translation of the talus in ankle stress radiography significantly improved (P < 0.05). In addition, signal changes in magnetic resonance imaging (MRI) improved in all patients. Visual Analogue Scale (VAS ) and The American Orthopaedic Foot & Ankle Society (AOFAS) scores also improved significantly (P < 0.05). No severe complications were observed.Conclusion DTO with joint distraction may be useful for older patients with a high physical activity level as joint preserving surgery for medial ankle osteoarthritis.

Outcomes and Gait Mechanics after Ankle Arthrodesis Take Down with Total Ankle Arthroplasty or Subtalar Fusion in Patients with Previous Tibiotalar Arthrodesis: A Comparative Study

Category: Ankle, Ankle Arthritis, Basic Sciences/Biologics, Hindfoot Introduction/Purpose: Ankle arthrodesis has traditionally been the treatment of choice for ankle arthritis. However, loss of range of motion, chronic pain, risk of nonunion, and potential risk of adjacent arthritis are ongoing concerns after this procedure. Most of surgeons state that subtalar fusion is an alternative to treat a painful and dysfunctional ankle fusion, but successful ankle arthrodesis take down using Total Ankle Arthroplasty (TAA) has been reported in the literature. The paucity of literature comparing these two treatment methods hinders the ability to make an informed decision on the best therapy. The purpose of the study was to compare patient-reported outcomes; gait mechanics and complications in patients with ankle arthrodesis take down using TAA to those who underwent subtalar fusion in a previously fused ankle. Methods: This is a comparative study of patients who underwent tibiotalar arthrodesis take down with total ankle arthroplasty and subtalar arthrodesis in previously arthrodesed ankles. Patients who were willing to take the gait mechanics test were included. They were distributed in two groups according to the undergone procedure. Postoperative outcomes consisted of patient- reported functional measures, and complications rate. Patient-reported functional measures included the American Orthopaedic Foot & Ankle Society Score (AOFAS) hindfoot scale, Visual Analogue Scale (VAS) for pain, and the Short Form 36 Health Survey (SF-36). Three-dimensional joint mechanics and ground reaction forces were measured during level walking at least one-year post surgery. Gait mechanics included spatiotemporal parameters, and the peak plantar and dorsiflexion moment. Data were analyzed using analysis of variance (ANOVA) to determine significant differences between the two groups. (a = 0.05). Results: Ten patients were included in the ankle arthrodesis taken down (AATD) group, and seven patients were included in the subtalar fusion (STF) group. The average follow-up time in the AATD and SFT group was 70.4 and 46 months, respectively P=0.14. There were no statistically significant differences in the demographics of both groups. The peak plantar flexion was 4.6 degrees and 1.3 degrees in the AATD and STF group, respectively; P=0.04. The range of motion in the sagittal plane was 11.5 degrees and 7.8 degrees in patients with AATD and STF groups, respectively; P=0.13. The complication rate was higher in the AATD group (7 patients, 70% vs 1 patient, 14%; P=0.02). There were no statistically significant differences in the patient-reported outcomes between the two groups. Conclusion: Patients with ankle arthrodesis taken down using total ankle arthroplasty as compared with patients with tibiotalocalcaneal arthrodesis have better range of motion of the hindfoot and improved gait mechanics. The improved cadence and mobility decreased the imbalance in the midfoot and forefoot during the gait. Nevertheless, due to the complexity of the procedure the complication rate is considerably higher. Further research with a larger sample of both groups may demonstrate greater differences in patient-reported outcomes.